One of the most common inquires I get is from new moms looking to lose that postpartum belly. How is it possible that celebrities like Heidi Klum can drop 30-40 pounds in just 4 months? Anna Paquin goes from twins to 6-pack abs in 5 months. For new moms, that is frustrating, when you work so hard to lose stubborn body weight. What do they do that you don’t? Trust me, there is no super-secret information or magic formula that only they are privy to. You have the same physiology and weight loss capabilities as Hollywood superstars.

Normal weight gain during pregnancy is 30-35 pounds. Roughly 10 pounds is lost immediately after birth – seven pounds for the baby, plus two-three for blood, amniotic fluid and other. Through the first week your body will flush another 5 pounds of reserved water weight. Optimal weight loss should be 1-2 pounds per week. If you do the math, you will find that Anna Paquin and Heidi Klum lost about 2 pounds per week. Suddenly, Heidi and Anna’s weight loss isn’t so dramatic, does it? A loss of 1-2 pounds per week is easily attainable if you are diet compliant and dedicated to exercise.

Phase I: Day 1 (or day cleared from physician) -5 weeks postpartum

In this phase your goal is to increase baseline fitness levels. Depending on your previous fitness level this stage can be progressed through quickly. In order to improve baseline cardiovascular levels it is best to start with steady state training. Steady state exercise is low intensity exercise that is done for an extended. Walking, jogging, or biking for 30 -60 minutes are good examples. The key in this training is that intensity level stays constant and relatively low. Intensity is low, with target heart rate (THR) of 50-65% of your max heart rate. Target heart rate can be determined using the following equation [(220-your age)*percent]. Bottom line, low and slow will build a base.

Developing and retraining postural and core musculature is vital following pregnancy. During pregnancy your postural muscles lengthen and tendons stretch. It is prudent to strengthen these structures as this will reduce injury risk and rebuild the core, the foundation of all movement. Good postural exercises are Kegels, abdominal bracing, and the drawing-in maneuver. In this phase you will start slow, but by the end of week 5 you should be exercising 5 days/ week for at least 30 minutes.

Phase II: 5-12 weeks postpartum

In this phase you are going to increase strength and train your heart to work at higher intensities. This is done through interval training. Take the baseline cardio program from phase one, but add in short bursts of high intensity exercise. For example, jog for 2 minutes, run at three-quarter speed for 30 seconds. Repeat the cycle of jog, run for a set period of time. The brief bouts of spiked heart rate increase your average heart rate during the workout.

Increasing strength is also very important and with a resistance circuit training program you can increase both cardio and strength. Circuit training is simply a series of exercises that are performed for a set time frame with minimal rest periods in between each exercise. Designing a circuit program is easy. Pick a series of 5-10 exercises. Alternate the exercises between upper body, lower body and total body. Here is sample 30 sec on /30 off program:

Push-up (30 seconds)

Rest (30 seconds) – Note: during your rest period get ready for the next exercise

Ball squat

Rest

Bent over row

Rest

Step-up with overhead press

Rest

Ab crunches

Rest

Repeat that cycle 5 times. Total workout time would be 25 minutes.

Phase III: 12 weeks – goal weight attainment

A word of caution: You should only workout in this phase if you have the physical ability to do so. In this phase the goal is to perform high intensity exercise for maximal caloric burn. Target heart rates in this phase are often 85-95%, which may not be suitable for everyone. If you have a history of cardiovascular disease or question your physical abilities seek consultation from a physician. If you are unable to exercise at this high-intensity, do not worry. An individual can easily exercise in phase II and still meet weight loss goals.

High intensity equals high calorie burn. In this phase you will perform exercises that elevate your heart rate to near maximal levels. Plyometric exercises, boxing, and jump rope are examples. Anna Paquin’s favorite exercise post pregnancy was boxing. Due to the high intensity, your workout time can be significantly reduced. Take a look at this workout comparison for a 30-year-old, 150 lb. female:

However, the caloric burn doesn’t stop there. Following a lower intensity workout your caloric burn will remain elevated for 2-6 hours. Following high intensity exercise caloric burn can remain elevated for as much as 18-24 hours. This means continued weight loss.

Diet is not to be forgotten about. A common myth is that nursing moms need to eat more, which leads many new moms to over eating. Nursing moms rarely need to increase diet intake more than 300 calories. Have a diet high in lean protein (fish, poultry, pork, eggs) as it suppresses hunger longer than a diet filled with processed carbohydrates. Fruits and vegetables should be your primary source of carbohydrates. Following a diet of lean protein, colorful fruits and vegetables ensures you are receiving much-needed vitamins, such as Vitamin A, D, E, K, B-complex and minerals like potassium, copper, zinc, iron and magnesium. A diet high in vegetables will also provide adequate fiber, which is good for postpartum moms to regain normal gastrointestinal function.

Weight loss is not rocket science. Keep it fun, simple, and stay compliant with your plan. You will get there.

This blog post is long overdue. I have had countless people – friends, family members, athletes, clients – all ask me about shin splints. What are they? How can I get rid of them? Can they be prevented? Despite being one of the most common athletic injuries, recreational or competitive, shin splints are easily treatable and very preventable. Too often sufferer’s deal with the pain and never fix the problem. My goal with this blog is to provide tips to fix the problem and resolve shin splint pain.

Shin splints, or Medial Tibial Stress Syndrome (MTSS), is a chronic injury typically described as dull-ache on the middle to inside portion of the lower leg. Pain is common during or after activity. In severe cases pain may last for several hours after activity and occasionally the individual will experience nighttime throbbing in the lower leg.

The pain from MTSS is attributed to irritation of the periosteum – a saran wrap like covering around bone – or a stress reaction to the underlying bone. Repetitive pounding or muscle pulling from these structures precipitates the injury. Popular belief is that shin splints are due to poor shoes, training intensity, and training surfaces. However, a critical review article written by Moen, Tol, et al., published in 2009 Sports Medicine found this was not the case. MTSS is often caused by poor joint movement and muscle imbalance. These movement patterns and muscle imbalances are easily identifiable. The best part is that you can fix these problems at home by following a simple flexibility and strengthening program.

First, let’s see if you have these movement dysfunctions. Observe yourself (in a mirror) walking or doing repeated squats. Do you see one or more of these four things: hips in, knees in, feet flatten, or toes point out? You may have one or all of these patterns; some may be extremely pronounced or could be very subtle. The image here shows a moderate to severe movement. If you observe this, even to the slightest degree, you are at risk for developing shin splints. Overtime these movement patterns create a muscle imbalance, where some muscles become overactive and some become underactive.

Using the above figure as an example, here are the typical overactive and underactive muscles we would see in a person with shin splints or with these movement patterns.

OVERACTIVE

UNDERACTIVE

Hip Flexors and Tensor Fascia Latae

Gluteal Group (Maximus, Medius)

Lateral calf (lateral gastrocnemius / soleus)

Medial Gastrocnemius

Groin muscles (adductor complex)

Anterior and Posterior tibialis

Biceps Femoris

Medial Hamstrings

Our goal is simple, turn-off the overactive and turn-on the underactive; simple as that. Below is a basic 3-step program that can help correct this issue, step 1 -Turn-off, step 2 – elongate, and step 3 – turn-on. This program can be done daily and would take no longer than 30 minutes from start to finish. Here is what a basic program would look like.

Step 1: Turn-off the overactive using a foam roller.

Gastrocnemius/Soleus

Adductors

TFL/IT-band

Foam roll each muscle for 90 seconds and hold tender areas for 20-30 seconds. A YouTube playlist created by friend and corrective exercise expert, Brent Brookbush, provides good examples and tips on how to perform these techniques.

Step 2 – Elongate the overactive with static stretching

Gastrocnemius/Soleus Static Stretch

Kneeling Hip Flexor Static Stretch

Adductor Static Stretch

Perform 1-2 sets of the stretch per muscle group and hold the stretch for a maximum of 30 seconds. Again, Brent has a good static stretching playlist that demonstrates these exercises.

Too often I see individuals with shin pain ceasing activity, buying new shoes, investing hundreds of dollars in custom orthotics, or giving themselves an ice bath. Shin splints do not have to be the end of training. Following a simple and structured program to correct of common movement dysfunction patterns you can eliminate shin splints and many other lower body injuries like Achilles pain, runner’s knee or hip pain.

My former co-worker giving me a stretch during the Spartan race after cramps set in.

A couple of weeks ago, I participated in a 5k and a 10k challenge that was scheduled 12 hours apart. Fitness enthusiasts would consider a back to back 5k / 10k as just another training session. I, on the other hand, am quite the opposite. I have developed a hate-hate relationship with aerobic exercise –specifically, running. I like speed, agility, quickness, strength, and power – arrg arrg arrg! I am five foot nothin’ and a hundred somethin’ (emphasis on the nothin’ and somethin’). I would rather pluck my eyelashes than run. But, I do love the exercise science.

You’d think I’d use my knowledge for exercise science as a useful tool. Unfortunately, my continued pursuit of knowledge does not translate to practical utility. What follows is what I should have done to enhance recovery and optimize performance during this short 12 hour recovery period between races. Since, I won’t listen to myself, maybe you will!

First, we must understand the physiology of producing energy, fatigue and recovery. I do not want to turn this in to an advanced exercise physiology session on metabolic pathways but this general background is helpful. When we exercise energy (ATP) is needed. This energy is created by our body using three systems: ATP-PCr system, the glycolytic system and the oxidative system. Each energy system has its own method of generating energy. Likewise, each energy system becomes fatigued after an imbalance occurs in its system.

In the ATP-PCr system our body uses stored Phosophocreatine and through a series of reactions quickly generates ATP. Unfortunately, this system gets depleted of stores rather quickly. This is why you can only perform and all out sprint for 10 – 20 seconds. After a 2 minute rest period the ATP resynthesizes giving you the ability to perform an all-out sprint again. If we going longer than 20 seconds our body must enter the glycolytic system. Here we begin to use glycogen to make energy. When glycogen is broken down without oxygen present, our cells becomes acidic (commonly known as lactic acid buildup or lactate threshold). This acidity inhibits enzyme activity. Since enzymes are the catalysts for almost all body functions, we fatigue when they stop working.

If intensity is low enough in the glycolytic system, our body has time to use oxygen to breakdown glycogen and prevent lactic acid build-up. This is the oxidative system. Using oxygen to breakdown glycogen is our long-term energy system, which we use to perform tasks like distance running. Carbohydrate is stored in our body as glycogen in muscle and liver. This is our preferred and primary energy source. However, when we exercise we deplete glycogen stores and sometimes have to call on fat to make energy. When we reach this phase our body will fatigue. So, in review, during high-intensity exercise we fatigue because we deplete ATP and Phosphocreatine stores. During moderate activity we fatigue due to lactate build-up. During long and steady state exercise we fatigue when glycogen stores become depleted.

To combat this fatigue we must train our body to adapt to these physiological changes, or provide opportunity for our body to recover through rest. You can also practice good post-exercise refueling habits. By eating and drinking macronutrients (carbohydrate, fat and protein) we replace what we just used. So, what do we eat and when do we eat to replenish?

A Study published by Howarth, et al., in 2009 found that ingesting a carbohydrate and protein mixture at a 4:1 ration provided the best benefits when compared to carbohydrates alone. Similarly, Koopman, et al., in 2005 found a 3:2 ration of carbohydrate to protein ingested post exercise was better than carbohydrate alone. The Koopman study also investigated the benefit of leucine – an essential amino acid found in soy, beef and salmon, known to facilitate muscle regeneration – and demonstrated an added benefit of this supplement. Even though some current data is contradictory most studies show that the amount of glycogen formed is significantly greater in athletes consuming the mixture of Carbohydrate and Protein.

Timing also plays an important role. You may have heard of nutrient timing – it’s getting a lot of attention lately. In order to compensate for protein loss during exercise, the timing of post-exercise protein supplementation is important. The efficiency of protein synthesis is improved by ingesting rapidly after exercise. Another challenge is the refueling with carbohydrates. Bottom line, the sooner carbohydrate is consumed post-exercise; the greater the amount of muscle glycogen is resynthesized. When time is short between fuel-demanding events, it makes sense to start refueling as soon as possible.

Keep it simple, post-exercise meals should be built on a foundation of carbohydrate-rich foods plus a smaller amount of protein. Greek yogurt or cottage cheese with fruit or bananas with peanut butter are both good options. If you are a stickler for protein powder, switch it up – make yourself a fruit smoothie and add a scoop of protein.

My times for the 5k and 10k were 29:37 and 63:26 respectively; certainly not awesome. Maybe if I’d apply what I know, I would have done better. Maybe if I replenished with a healthy carbohydrate protein drink instead of beer and pizza, I would have done better on day 2. If I’d just listen to my brain and not my fat cells I might have finished under 60 minutes. If I’d listen to my brain, not watch the ESPN, I could improve. If I chose to get up rather than drool on my pillow, I might approach 45 minutes. Someday I will get the hint and practice what I preach. Maybe I need the late Chris Farley’s famous character, Matt Foley, as my personal motivational speaker.

I have been looking for something to blog. No idea surfaced that said, “Yes, that is a great blog idea.” That was until yesterday’s tragic Boston Marathon bombing. Runners are a rare breed. You cannot keep them down. A runner’s passion for sport, resilience to challenge, and unique characteristic to rise above is unparalleled by any other athlete. I am not a runner. In fact I am the antithesis of a runner. I go in to anaphylactic shock just hearing the word aerobic exercise, but have many friends who are passionate runners. I dedicate this blog to my running friends, competitors of the Boston Marathon, the friends and family of those impacted by yesterday’s events, and runners everywhere from the competitive to non-competitive. I will keep it true to my blog site and remain sports medicine focused. I hope you find the information useful.

Running is one of the most popular recreational sports in the US. Race events can be found in almost every town. My town – Champaign, IL – has 2 events in the next 4 weeks. Some estimates say 20% of the population is runners and 10% of these people participate in race events. The benefits of exercise are well documented. Running has shown to build confidence and character, reduce stress and improve mood. However, the due to their very nature – the unwillingness stop – running does bring about an increased incidence of musculoskeletal injury.

You don’t need to be an astrophysicist to know running injury is secondary to cumulative overload. Running injuries are multifactorial; neuromuscular imbalance, poor arthrokinematics and other things such as age, nutritional status and environment are to blame. From a biomechanical point of view frontal plane knee adduction moments play a significant role in lower extremity injury. Q-angle – a measure of knee alignment – can indicate risk for running injury. An increased Q-angle can be a result of many neuromusculoskeletal inefficiencies from poor muscular hip control to limited ankle dorsiflexion and excessive forefoot pronation.

Running brings about many injuries, but the most common are Patellofemoral Syndrome, Iliotibial Band Syndrome, Medial Tibial Stress Syndrome / Tibial Stress Fracture, Achilles Tendinitis, Plantar Fasciitis, and Sacroiliac Joint Pain. What is interesting is that all of these injuries can be caused by biomechanical breakdown and neuromusculoskeletal inefficiency. The good is the dysfunctional patterns are identifiable, preventable and correctable. Below is a sample 15 minute injury prevention program from a blog I wrote in Sept 2012. Yes, 15 minutes is all you need to prevent many running injuries.

Beyond the correction of movement dysfunction there are alternatives to treat running injuries which are effective and gaining popularity. This table highlights a few.

Prolotherapy

This has been around since the late 1800’s, but has since become popular. The basis of prolotherapy is that it expedites healing by increasing fibroblastic activity and collagen repair.

Autologous Blood

Blood is the medium that carries tissue repairing materials to injury sites. However, sometimes, blood cannot deliver adequate amounts of material to the injured area. Thus, injections directed right at the injury site deliver tissue repairing material.

Despite the negative press and belief that stem cells are only derived from an unborn fetus, stem cells do come from other sources – such as bone marrow. By taking stem cells from bone marrow and injecting in to damaged areas will facilitate tissue repair.

ESWT

Extracorporeal Shock Wave Therapy might best be known as lithotripsy. Lithotripsy is a procedure in which sound waves blast and destroy kidney stones. ESWT is the use of sound waves to destroy calcific tendons and ligaments.

I prefer preventing and rehabilitating injury through correcting neuromuscular inefficiencies and dysfunctional movement. The problem with the above treatments is that they are treatments. If an injury is caused by dysfunctional movement patterns and those patterns are not corrected it is likely the above treatments will simply serve as a Band-Aid because the true problem was not fixed.

If the person(s) responsible for the Boston Marathon bombing were looking to put fear in people, they chose the wrong population to target. Runners are the most stubborn and prideful athletes. No means yes, and yes means do more. If you took a graphical representation of marathon registration numbers from last night through the end of this week I would bet you’d find a spike, rather than a decline. Social media is exploding with a rise of the runner. A quote from a friends Facebook page: “If you’re trying to defeat the human spirit, marathoners are the wrong group to target” –unknown. Other movements like, wear a race shirt tomorrow, donations, and wear yellow and blue (Boston Marathon colors) have already begun. So, thank you runners for inspiring this blog post!

Each day we are bombarded with new data. My goal is to share a breakdown of what I have discovered and read this past month. There is a little something for everyone here. How do I choose which articles to share? Is it clinically relevant? Does the story share something new or raise an interesting question? Most studies have some internal flaw that can be poked and while I try to only share those having high quality, my number one goals is to share something unique, progressive or surprising.

Published research:

In the recent release of The American Journal of Clinical Nutrition there is a good article supporting the benefits of a high-protein breakfast. Data reveals that a high-protein diet alters ghrelin and peptide YY concentrations subsequently leading to decreased appetite and also curbed late night snacking. Is this study perfect – no. But it is pretty darn good – Yes. I have been blogging on this topic for sometime. Where, when and why did the public begin thinking high protein intake is unhealthy? Did you know quality of protein is measured by how it compares to egg protein? That is because the protein in egg, albumin, has near perfect amino acid distribution. Yet many consider eggs bad.

Here is another topic area I have been yapping about for some time – risk factors for hamstring strains. This systematic literature review was first published online and is now in print in the latest edition of the British Journal of Sports Medicine. This SLR included 34 articles for review, which is a pretty good number to include. Unfortunately, only 1 evaluated hip extension strength. Three found decreased hip extension ROM measures indicating shortened hip flexors. It baffles me as to why studies do not look at glute weakness and hip flexor tightness as a risk factor for hamstring strains. I’ve written about this and hope someday a good study will come out and study the correlation.

Mild Traumatic Brain Injury – MTBI is getting a lot of media attention lately and rightfully so. NFL labor union disputes and an enormous amount of published research has athletes and parents taking MTBI seriously. If that wasn’t enough, Junior Seau’s suicide was linked to depression secondary to chronic TBI. In the Archives of Physical Medicine and Rehabilitation, April 2013 issue, an article discusses depression after TBI. It’s a nice short quick-hitting synopsis, with full-text available.

Website finds:

I subscribe to daily email updates from ScienceDialy. Two or three times per week they share something good that I get caught reading. Two articles they shared link positive benefits of Vitamin D. One shows that Vitamin D replacement improves muscle efficiency and another found Vitamin D may lower diabetes risk in children. Now I am not advocating to go overboard on Vitamin D, but I am saying drink Vitamin D fortified milk and cereals and get outside in the sun to ensure you are getting adequate vitamin D.

There are so many smart people out there and I enjoy learning from them all. Here are some good blog posts from this month.

The first is from Sport Injury Matt (@SportInjuryMatt – twitter handle). He had two posts about foot mechanics and foot wear. Part I shares good crucial information on foot mechanics. Part II of this post talks about what one should run in and considerations when selecting certain shoes.

My good friend Jay Barss (@sportsrehabtalk – twitter handle) is new to the blog and twitter world. He is a smart dude and deserves some following. His most recent post talks about the a new perspective on management on patellofemoral pain management. As we all know, correction of faulty movement patterns is critical in management of the oft-diagnosed PFPS.

Last is a series posted by Allan Besselink (@abesselink – twitter handle). If you have not followed Allan’s blog I highly recommend it. In fact his blog was recently nominated as top choice for health and wellness. Everything he posts is high quality. I particularly liked his three-part series titled the Low Back Pain Paradox. Low back pain effects 80% of the adult population and Allan does a great job covering all the bases in Part I, Part II, and Part III.

For many, “cardio” sucks. Running – the boring monotonous “fat-burning” exercise that is nothing more than audbile thud, thud, thud of a foot slap whilst staring at mindlessly at CNN Breaking news on the overhead TV monitors. Some meathead gets on the machine next to you and insists on going 1% steeper grade and .1 MPH faster. You try the elliptical, which has absolutely zero relationship to how we move everyday, unless you have discovered an amazing pair of Back To the Future-esk sneakers that allow you to air pedal instead of walk. Then there are those who need upper body rest and choose to bike. Or better yet, if you are really tired you can choose the recumbent bike that is perfect for people who want to lie down while exercising.

For the “cardio” lovers out there; I get it, “cardio” can be awesome and burn calories. I get there are many training programs. So, before you get on your soapbox to scream “CARDIO ROCKS”; [relax, breath – this might sting] not everyone shares your opinion. For many “cardio” sucks.

By now you have likely noticed the quotes around “cardio”. People describe “cardio” as running, stairclimber, elliptical, biking or swimming. It’s not. Cardio – short for cardiovascular or cardiorespiratory and synonymous with aerobic exercise – is simply the act of raising your heart rate for an extended period of time (> 5 minutes) without allowing it to recover. That’s right, anything you do to increase heart rate for the duration of the workout is technically cardio. The best way to do this is by doing a circuit training program.

Circuit training is simply a series of exercises that are performed for a set of repetitions or time frame with minimal rest periods (<40 seconds) in between each exercise. The short rest period is the crucial component as it will not allow your heart rate to recover, which is why circuit training can be a cardio or aerobic exercise.

Designing a circuit program is easy. Pick a series of 5-10 exercises. Alternate the exercises between upper body, lower body and total body. Design your workout with 1 minute increments that have an “on” time (period of doing the exercise) and an “off “time (period of rest). For example, exercise for 30 seconds, rest for 30 seconds. Here is what a program might look like if doing a 30 on/30 off:

You can make the circuit harder or easier by manipulating the rest time or changing the intensity of the exercise. Here is a harder circuit program using the same 30 on/30 off time, but with more intense exercises:

Need it more intense? Repeat the cycle 7 times. Still not enough – decrease your rest time so “on” time is 40 or 45 seconds and the rest period is 15-20 seconds. Trust me, if you can do the above workout with a 45/15 on/off time for 7 cycles, you don’t need to read this. You should be competing at the next Ironman.

The beauty of circuit training is that it defeats monotony. You can plug any exercise in to the circuit routine. You can do this program 5 days per week and never do the same exercise twice. Use your imagination.

“But will I get the same calorie burn as I would with running?” No, you will have more!! Exercises in a circuit program are more intense than a steady state cardio. Your heart rate will shoot up during the “on” time creating a higher peak heart rate. Since the rest period is short, you will also have a higher average heart rate. Higher heart rate = higher caloric burn.

More positives; because the intensity is higher you can achieve the same caloric burn in less time. Which would you rather do: spend 60 minutes to burn 400 calories on an elliptical or 25 minutes doing a variety of things? Want more – your circuit program has weight training in it. Not only are you getting cardio, you are lifting – two birds, one stone.
Finally, no blog of mine could be mine without a little bit of geeky-ness. The concept of EPOC or excess post-exercise oxygen consumption. We need oxygen to feed our cells and produce energy. When you perform high-intesity exercise – like that in a circuit program – you create an oxygen debt. In a sense your body is starving for oxygen. After exercise your body must continually consume oxygen to make up for the debt. This is metabolism and extended caloric burn. With a circuit program the oxygen debt is greater than that of traditional “cardio”. Thus, you continue to have increased metabolism for 12-24 hours after the exercise. With a slow steady state “cardio” exercise, your metabolism is done after 2-4 hours.

See, cardio doesn’t have to suck. However, if you are hell-bent on strolling along on that elliptical while reading 10 chapters of the latest John Sanford novel – have fun.

Overview and Introduction:Vladamir Janda revolutionized human movement dysfunction and rehabilitation when he described three compensatory movement patterns as a result of pattern overload and static posturing. Most musculoskeletal injuries are multifactorial, but more often than Janda’s described three compensation patterns – upper crossed syndrome, lower crossed syndrome and pronation distortion syndrome – are the key contributor to our pain complaints.

Since Janda introduced this topic research has continued to answer what and why questions surrounding these compensatory patterns. We have learned hypertonic / hypotonic muscles and the delicate interplay they have on integrated functional movement. Studies continue to show how these dysfunctional patterns lead to our most common injuries – PFPS, ITBS, Achilles tendinopathy, plantar fasciitis, epicondylopathy, biceps tendinosis, impingement syndromes, MTSS, etc.

As research evolves we continue to fine-tune our clinical decision making. For several years now rehabilitation journals have published articles linking a myriad of injuries to lower-crossed syndrome, gluteal inhibition, and over-activation of the tensor fasciae latae (TFL). We have learned that these should be a focal point in our rehabilitation techniques to resolve lower extremity overuse injuries. The article by Selkowitz, et al., in the Feb 2103 edition of JOSPT is unique and what I believe to be one of the most clinically relevant studies to be published in the last few months. I liked it so much I had to blog it.

Statement of the Problem:
A common descriptor associated with lower-crossed syndrome is femoral internal rotation and hip adduction. From a rehabilitation perspective we must enhance neuromuscular firing of hip abduction and external rotation. In addition we must inhibit over activity of hip adductors and hip internal rotators.

As a health care practitioner we understand the delicate interplay of functional anatomy. The problem is how do we inhibit a chronically hypertonic TFL while activating the hypotonic gluteal group if they both produce similar movements? It is a fine balance we must be cognizant of when designing rehabilitation programs.

This study examined which exercises elicit the greatest gluteal (medius / maximus) activation while minimizing activation of the TFL. This is exactly what we need to know when designing a rehabilitation program to target lower crossed compensatory patterns.

Results:Seven of the 11 exercises -bilateral bridge, unilateral bridge, side step, clam, squat and two quadruped variations – demonstrated statistically significant greater muscle activation in the gluteus medius and gluteus maximus when compared to the TFL. Side-lying hip abduction, hip hike, the lunge, and the step-up were either not significant or demonstrated higher TFL values compared to the gluteal group.

The authors ranked the exercises in order of highest gluteal to TFL ratios. Clam, side step, and unilateral bridge had the highest ratios, while lunge, hip hike, and squat had the lowest ratios.

Clinical Application of Data:
Altered arthrokinematics and muscle imbalances are a common cause of overuse injuries. Lower-crossed syndrome is a common compensatory pattern that is associated with hypertonicity of the hip flexors complex, which elicits altered reciprocal inhibition of the gluteal group. Targeting this dysfunctional pattern using proper exercise selection indicated here can prevent injuries, improve patient outcomes, and restore optimal function. When designing your program be sure to reference the material here to determine a proper rehabilitation program.

Limitations:
Studies are equivocal on reliability of surface EMG vs intramuscular. However, the authors cite using the method by Delagi and Perotto, which appears reliable. Still one has to question specificity and sensitivity to a minimal degree.

The participants were instructed on proper exercise technique. However, substitutions patterns are common in patients exhibiting muscle imbalance. Any slight deviation from proper technique can skew the data. I am curious how closely exercise technique was monitored and what occurred when deviation did occur.

Summary:
Like I said from the top, rarely do we have a published data with such clinical relevance. Studies that show how deep ultrasound penetrates a rats muscle are great, but clinically have little clinical utility. Data revealed here will guide decision making on proper exercise selection and ensure they are applying the proper strengthening exercise to specifically target the underactive glutes while avoiding the over active TFL. Kudos to the authors.